Rana Salem

The 7-Item Generalized Anxiety Disorder Scale as a Tool for Measuring Generalized Anxiety in Multiple Sclerosis

BACKGROUND Generalized anxiety disorder (GAD) is common in multiple sclerosis (MS) but understudied. Reliable and valid measures are needed to advance clinical care and expand research in this area. The objectives of this study were to examine the psychometric properties of the 7-item Generalized Anxiety Disorder Scale (GAD-7) in individuals with MS and to analyze correlates of GAD. METHODS Participants (N = 513) completed the anxiety module of the Patient Health Questionnaire (GAD-7). To evaluate psychometric properties of the GAD-7, the sample was randomly split to conduct exploratory and confirmatory factor analyses. RESULTS Based on the exploratory factor analysis, a one-factor structure was specified for the confirmatory factor analysis, which showed excellent global fit to the data (χ(2) 12 = 15.17, P = .23, comparative fit index = 0.99, root mean square error of approximation = 0.03, standardized root mean square residual = 0.03). The Cronbach alpha (0.75) indicated acceptable internal consistency for the scale. Furthermore, the GAD-7 was highly correlated with the Hospital Anxiety and Depression Scale-Anxiety (r = 0.70). Age and duration of MS were both negatively associated with GAD. Higher GAD-7 scores were observed in women and individuals with secondary progressive MS. Individuals with higher GAD-7 scores also endorsed more depressive symptoms. CONCLUSIONS These findings support the reliability and internal validity of the GAD-7 for use in MS. Correlational analyses revealed important relationships with demographics, disease course, and depressive symptoms, which suggest the need for further anxiety research.

Use of and confidence in administering outcome measures among clinical prosthetists: Results from a national survey and mixed-methods training program.

Background: Outcome measures can be used in prosthetic practices to evaluate interventions, inform decision making, monitor progress, document outcomes, and justify services. Strategies to enhance prosthetists’ ability to use outcome measures are needed to facilitate their adoption in routine practice. Objective: To assess prosthetists’ use of outcome measures and evaluate the effects of training on their confidence in administering performance-based measures. Study design: Cross-sectional and single-group pretest–posttest survey. Methods: Seventy-nine certified prosthetists (mean of 16.0 years of clinical experience) were surveyed about their experiences with 20 standardized outcome measures. Prosthetists were formally trained by the investigators to administer the Timed Up and Go and Amputee Mobility Predictor. Prosthetists’ confidence in administering the Timed Up and Go and Amputee Mobility Predictor was measured before and after training. Results: The majority of prosthetists (62%) were classified as non-routine outcome measure users. Confidence administering the Timed Up and Go and Amputee Mobility Predictor prior to training was low-to-moderate across the study sample. Training significantly (p < 0.0001) improved prosthetists’ confidence in administering both instruments. Conclusion: Prosthetists in this study reported limited use of and confidence with standardized outcome measures. Interactive training resulted in a statistically significant increase of prosthetists’ confidence in administering the Timed Up and Go and Amputee Mobility Predictor and may facilitate use of outcome measures in clinical practice. Clinical relevance Frequency of outcome measure use in the care of persons with limb loss has not been studied. Study results suggest that prosthetists may not regularly use standardized outcome measures and report limited confidence in administering them. Training enhances confidence and may encourage use of outcome measures in clinical practice.

Symptoms and quality of life indicators among children with chronic medical conditions

BACKGROUND Children with chronic conditions often experience numerous symptoms, but few research studies examine patterns of symptoms and quality of life (QoL) indicators. OBJECTIVE To examine if reliable latent classes of children with chronic medical conditions can be identified based on the clustering of symptoms and QoL indicators. METHODS Structured interviews were conducted with children ages 9-21 living with chronic medical conditions (N = 90). Multiple symptoms (e.g., pain, sleep, fatigue, and depression) and QoL indicators (e.g., life satisfaction and social support) were measured. Physical health and emotional, social, and school functioning were measured using the Pediatric Quality of Life Inventory (PedsQL). Latent class analysis was used to classify each child into a latent class whose members report similar patterns of responses. RESULTS A three-class solution had the best model fit. Class 1 (high-symptom group; n = 15, 16.7%) reported the most problems with symptoms and the lowest scores on the QoL indicators. Class 2 (moderate-symptom group; n = 39, 43.3%) reported moderate levels of both symptoms and QoL indicators. Class 3 (low-symptom group; n = 36, 40.0%) reported the lowest levels of symptoms and the highest scores on the QoL indicators. CONCLUSIONS The three latent classes identified in this study were distributed along the severity continuum. All symptoms and QoL indicators appeared to move in the same direction (e.g., worse symptoms with lower QoL). The PedsQL psychosocial health summary score (combining emotional, social, and school functioning scores) discriminated well between children with different levels of disease burden.

Obesity and symptoms and quality of life indicators of individuals with disabilities

BACKGROUND Health risks of obesity are well known, but effects of obesity on health-related quality of life (HRQOL) have not been well-studied in people with physical disabilities. OBJECTIVE/HYPOTHESIS We examined the association between obesity and HRQOL in people with disabilities relative to the general US population. We hypothesized (a) overall, individuals with disabilities will report worse HRQOL than the general US population and (b) obese individuals with disabilities will report worse HRQOL than non-obese individuals. METHODS Individuals with muscular dystrophy, multiple sclerosis, post-polio syndrome, and spinal cord injury (N = 1849) completed Patient Reported Outcomes Measurement Information System (PROMIS) measures of fatigue, pain interference, physical and social function, depression, sleep disturbance, and sleep-related impairment. Participants were classified as obese or non-obese based on self-reported weight and height (BMI) and/or waist circumference (WC). PROMIS T-scores were compared to norms and between obesity groups. RESULTS Mean BMI was 26.4 kg/m(2) with 23.4% classified as obese. Mean WC was 37.5 inches (males) and 34.0 inches (females); 26.4% reported abdominal obesity. Based on BMI and/or WC, 33.3% (n = 616) were classified obese. Compared to PROMIS norms, obese individuals reported worse HRQOL on all domains (p < 0.0001). Compared to non-obese individuals, obese individuals reported worse functioning on all domains except depression (p < 0.01). Obese individuals with MS and MD reported worse outcomes than non-obese counterparts. CONCLUSIONS Obesity in people with physical disabilities is associated with poorer HRQOL. More research is needed to inform clinicians in identifying obese patients and helping them achieve healthy weight, reduce symptom burden, and improve QOL.

Self-Reported Cognitive Concerns in People With Lower Limb Loss

OBJECTIVES To investigate differences between self-reported cognitive concerns in people with lower limb loss (LLL) and normative data derived from the U.S. general population, and secondarily to determine whether there were cognitive differences based on amputation etiology or age. DESIGN Survey. SETTING General community. PARTICIPANTS A volunteer sample of persons with LLL (N=1086) resulting from trauma or dysvascular complications who regularly use a prosthetic limb. INTERVENTIONS Not applicable. MAIN OUTCOME MEASURE The Quality of Life in Neurological Disorders Applied Cognition-General Concerns Short Form version 1.0 (Neuro-QoL ACGC), an 8-item self-report measure of general cognitive concerns. RESULTS People with LLL reported significantly more cognitive concerns than the Quality of Life in Neurological Disorders normative sample. Mean Neuro-QoL ACGC scores were significantly lower than normative values (P<.001) across subgroups defined by age (ie, <40, 40-49, 50-59, 60-69, and 70+ years) and subgroups defined by etiology (ie, traumatic and dysvascular LLL). However, there were no significant differences in cognitive concerns among age subgroups (P=.84) or between the etiology subgroups (P=.58). CONCLUSIONS When compared with the Quality of Life in Neurological Disorders normative sample, individuals with LLL report greater concerns with cognitive health. Cognitive concerns were not differentially affected by age or cause of amputation. The presence of cognitive concerns in people with LLL suggests a need to assess perceived cognitive function in order to tailor education and training in prosthetic use and care.

Development and validation of a new self-report measure of pain behaviors.

Summary A new measure, the Pain Behaviors Self Report (PaB‐SR), provides a valid tool with which to explore relationships between pain behaviors and pain correlates. Abstract Pain behaviors that are maintained beyond the acute stage after injury can contribute to subsequent psychosocial and physical disability. Critical to the study of pain behaviors is the availability of psychometrically sound pain behavior measures. In this study we developed a self‐report measure of pain behaviors, the Pain Behaviors Self Report (PaB‐SR). PaB‐SR scores were developed using item response theory and evaluated using a rigorous, multiple‐witness approach to validity testing. Participants included 661 survey participants with chronic pain and with multiple sclerosis, back pain, or arthritis; 618 survey participants who were significant others of a chronic pain participant; and 86 participants in a videotaped pain behavior observation protocol. Scores on the PaB‐SR were found to be measurement invariant with respect to clinical condition. PaB‐SR scores, observer reports, and the videotaped protocol yielded distinct, but convergent views of pain behavior, supporting the validity of the new measure. The PaB‐SR is expected to be of substantial utility to researchers wishing to explore the relationship between pain behaviors and constructs such as pain intensity, pain interference, and disability.

Prosthetists’ perceptions and use of outcome measures in clinical practice: Long-term effects of focused continuing education

Background: Continuing education is intended to facilitate clinicians’ skills and knowledge in areas of practice, such as administration and interpretation of outcome measures. Objective: To evaluate the long-term effect of continuing education on prosthetists’ confidence in administering outcome measures and their perceptions of outcomes measurement in clinical practice. Design: Pretest–posttest survey methods. Methods: A total of 66 prosthetists were surveyed before, immediately after, and 2 years after outcomes measurement education and training. Prosthetists were grouped as routine or non-routine outcome measures users, based on experience reported prior to training. Results: On average, prosthetists were just as confident administering measures 1–2 years after continuing education as they were immediately after continuing education. In all, 20% of prosthetists, initially classified as non-routine users, were subsequently classified as routine users at follow-up. Routine and non-routine users’ opinions differed on whether outcome measures contributed to efficient patient evaluations (79.3% and 32.4%, respectively). Both routine and non-routine users reported challenges integrating outcome measures into normal clinical routines (20.7% and 45.9%, respectively). Conclusion: Continuing education had a long-term impact on prosthetists’ confidence in administering outcome measures and may influence their clinical practices. However, remaining barriers to using standardized measures need to be addressed to keep practitioners current with evolving practice expectations. Clinical relevance Continuing education (CE) had a significant long-term impact on prosthetists’ confidence in administering outcome measures and influenced their clinical practices. In all, approximately 20% of prosthetists, who previously were non-routine outcome measure users, became routine users after CE. There remains a need to develop strategies to integrate outcome measurement into routine clinical practice.

Laboratory- and community-based health outcomes in people with transtibial amputation using crossover and energy-storing prosthetic feet: A randomized crossover trial

Contemporary prosthetic feet are generally optimized for either daily or high-level activities. Prosthesis users, therefore, often require multiple prostheses to participate in activities that span a range of mobility. Crossover feet (XF) are designed to increase the range of activities that can be performed with a single prosthesis. However, little evidence exists to guide clinical prescription of XF relative to traditional energy storing feet (ESF). The objective of this study was to assess the effects of XF and ESF on health outcomes in people with transtibial amputation. A randomized crossover study was conducted to assess changes in laboratory-based (endurance, perceived exertion, walking performance) and community-based (step activity and self-reported mobility, fatigue, balance confidence, activity restrictions, and satisfaction) outcomes. Twenty-seven participants were fit with XF and ESF prostheses with standardized sockets, interfaces, and suspensions. Participants were not blinded to the intervention, and wore each prosthesis for one month while their steps were counted with an activity monitor. After each accommodation period, participants returned for data collection. Endurance and perceived exertion were measured with the Six-Minute Walk Test and Borg-CR100, respectively. Walking performance was measured using an electronic walkway. Self-reported mobility, fatigue, balance confidence, activity restrictions, and satisfaction were measured with survey instruments. Participants also reported foot preferences upon conclusion of the study. Differences between feet were assessed with a crossover analysis. While using XF, users experienced improvements in most community-based outcomes, including mobility (p = .001), fatigue (p = .001), balance confidence (p = .005), activity restrictions (p = .002), and functional satisfaction (p < .001). Participants also exhibited longer sound side steps in XF compared to ESF (p < .001). Most participants (89%) reported an overall preference for XF; others (11%) reported no preference. Results indicate that XF may be a promising alternative to ESF for people with transtibial amputation who engage in a range of mobility activities. Trial registration: ClinicalTrials.gov NCT02440711

Do measures of depressive symptoms function differently in people with spinal cord injury versus primary care patients: the CES-D, PHQ-9, and PROMIS®-D

PurposeTo evaluate whether items of three measures of depressive symptoms function differently in persons with spinal cord injury (SCI) than in persons from a primary care sample.MethodsThis study was a retrospective analysis of responses to the Patient Health Questionnaire depression scale, the Center for Epidemiological Studies Depression scale, and the National Institutes of Health Patient-Reported Outcomes Measurement Information System (PROMIS®) version 1.0 eight-item depression short form 8b (PROMIS-D). The presence of differential item function (DIF) was evaluated using ordinal logistic regression.ResultsNo items of any of the three target measures were flagged for DIF based on standard criteria. In a follow-up sensitivity analyses, the criterion was changed to make the analysis more sensitive to potential DIF. Scores were corrected for DIF flagged under this criterion. Minimal differences were found between the original scores and those corrected for DIF under the sensitivity criterion.ConclusionsThe three depression screening measures evaluated in this study did not perform differently in samples of individuals with SCI compared to general and community samples. Transdiagnostic symptoms did not appear to spuriously inflate depression severity estimates when administered to people with SCI.

Somatic Symptoms of Depression and Anxiety in People with Multiple Sclerosis

Background People with multiple sclerosis (MS) are at increased risk for depression and anxiety. The symptoms of MS are often similar to the somatic or physical symptoms of depression and anxiety (fatigue, trouble concentrating). This study examined whether MS symptoms and effects biased the assessment of somatic symptoms of anxiety and depression. Methods People with MS (n = 513) completed a survey about MS symptoms, treatments, and distress. The Patient Health Questionnaire-9 assessed depression, and the patient-report version of the Primary Care Evaluation of Mental Disorders assessed anxiety. Participants were grouped into low versus high MS symptoms based on self-reported symptoms and as high versus low disability by the Expanded Disability Status Scale (EDSS). Groups were compared using differential item functioning analysis. Results No bias was found on somatic symptoms of depression comparing high versus low MS symptom groups (P > .15) or comparing groups based on EDSS scores (P > .29). Two anxiety symptoms (fatigue and muscle tension) showed bias comparing high versus low MS symptom groups (P < .01) and comparing high versus low groups based on EDSS scores (P ≤ .01). Intraclass correlations suggested a small effect due to bias in the somatic symptoms of anxiety. Conclusions Somatic symptoms of depression are unlikely to be biased by MS symptoms. However, the use of certain somatic symptoms to assess anxiety may be biased for those with high MS symptoms.